Provider Demographics
NPI:1619435260
Name:SMITH, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6074 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1286
Mailing Address - Country:US
Mailing Address - Phone:910-302-1438
Mailing Address - Fax:
Practice Address - Street 1:6074 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1286
Practice Address - Country:US
Practice Address - Phone:910-302-1438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-03
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle